Primary Health Exam 3 Review Men's Health PDF

### **Primary Health Exam 3 Review** ### **Men's Health** **Prostate Screening Guidelines**: USPSTF recommends against routine screening. ACS and AUA guidelines recommend individualized approach with shared decision making on whether ADRE and PSA screening together are in the patient\'s best int...

### **Primary Health Exam 3 Review** ### **Men's Health** **Prostate Screening Guidelines**: USPSTF recommends against routine screening. ACS and AUA guidelines recommend individualized approach with shared decision making on whether ADRE and PSA screening together are in the patient\'s best interest. For most men, screening with PSA and DRE starting at the age of 50. Consider screening at 45 for those at high risk (1stdegree relative with prostate cancer before the age of 65 black ethnicity). For men with more than one first- degree relative with history of prostate cancer, begin screening at the age of 40. Asymptomatic men with 10-year life expectancy should not be offer a PSA testing. Routine screening for prostate cancer involves PSA testing and digital rectal examination. PSA levels above 4 ng/mL may warrant further investigation (e.g., biopsy or imaging). Screening frequency depends on risk factors, including age, family history, and ethnicity. **Risk Factors**: Age: Risk increases after age 50. Family history of prostate cancer. African American ethnicity. Diet high in red meat and low in fruits and vegetables. **Diagnostics**: Digital Rectal Exam (DRE): Palpable abnormalities suggest malignancy. Prostate-Specific Antigen (PSA) Testing: Elevated levels require follow-up. Prostate specific antigen (PSA) usually \< 4 ng/mL. However, PSA can be normal. Evaluate velocity of change in PSA and use in conjunction with digital rectal exam (DRE). A PSA value \> 10ng/mL generally necessitates biopsy. A PSA value \> 4 -- 9.9ng/mL usually is biopsied, but only 20% of these patients have prostate cancer. Prostate cancer antigen 3, TMPRSS2 -- ERG gene fusion, and prostate health index are infrequently used by clinicians, but are adjunct tests to use with PSA. Alkaline phosphate: elevated with metastasis. Testosterone and liver function test if provided suspect androgen deprivation. Transrectal biopsy with transrectal ultrasound TRUS) guidance prostate biopsy. CT, primarily to evaluate the size of the prostate and assess for pelvic lymph node involvement in the preoperative. For staging purposes or evaluation of metastasis. MRI and bone scan if evidence of no involvement, PSA \> 20ng/mL or Gleason Score \> 8; Gleason score \> 8 indicates cancer more likely to spread rapidly. Bones can: positive if metastasis (always indicated if PSA \> 20). **Referral and Follow-Up**: Clinical examination with PSA every 6 months for 5 years, then annually; DRE annually. If patient is under active surveillance, follow up should include repeat prostate biopsies 1 year after original diagnosis coma then every 2 to 4 years to monitor progression. Men treated with antiandrogen deprivation therapy(ADT) require evaluation for CVD and prevention. Screening for urinary tract dysfunction and sexual dysfunction; treat symptomatically. Screening for depression, anxiety, suicidality, and caregiver distress. Urologist consultation for elevated PSA or abnormal DRE. Biopsy for confirmed diagnosis. **Testicular Cancer** Malignant tumor of the testicle. Two types of testicular cancer have been identified: Germ cell (90-95% of the cases: seminoma, teratoma, teratocarcinoma, and embryonal carcinoma). Nongerm cell - (5 -- 10% of cases: Leydig cell, gonadoblastoma, adenocarcinoma). **Screening**: With early detection, testicular cancer is one of the most curable solid cancers in the United States. Controversy surrounds the initiation of monthly self-testicular examinations in adolescence. Boys with cryptorchidism are encouraged to undergo orchiopexy before age 13. **Risk Factors**: history of cryptorchidism (even if repaired), family history of testicular cancer, and previous history of testicular cancer, testicular atrophy. White race; rare in Black people, gonadal dysgenesis. **Assessment Findings**: Symptoms may include painless testicular mass, swelling, or discomfort. The affected testicle may feel harder than normal. Solid, firm, non-tender, unilateral testicular mass. Sensation of fullness, heaviness, or dull ache in scrotum, lower abdomen, or perennial area. Previous mole testicle and largest to size of normal testicle. Hydrocele. Gynecomastia in 5% of patients with germ cell tumors. Mass does not transilluminate. Erectile dysfunction and or loss of libido. **Treatment**: typically involves surgical removal of the affected testicle (orchiectomy), followed by chemotherapy or radiation if the cancer has spread. Non-pharmacologic management: Active surveillance, surgical intervention: radical orchiectomy in all testicular cancers, regardless of staging. Radiation therapy. Pharmacological management: chemotherapy: cryopreservation of sperm should be discussed prior to initiation of treatment; type of chemotherapy treatment depends on type of cancer: seminoma or non-seminoma. Who is at most risk for testicular cancer: prior cryptorchidism, white race, and family history Treatment for stage 1 testicular cancer: surgery radical orchiectomy and radiation. **Referral and Follow-up**: Referral to a urologist or oncologist for evaluation and treatment. Close monitoring of hCG, LDH an alpha-fetoprotein for indication of therapy response and recurrence. Periodic chest and abdominal CT for detection of metastasis. Follow up is largely dictated by the type of cancer and treatment. Typically, initial office visits are everyone 1-2 months after orchiectomy with adjuvant therapy. For patients with orchiectomy, and adjuvant therapy initial follow up is every 3-4 months. Frequency tapered, if no evidence of relapse. Regular follow-up with a urologist is necessary for surveillance of potential recurrence. Routine self-exams can be encouraged to catch early signs of recurrence (Dunphy et Al. 2022). **Cryptorchidism --** Undescended testicle. incomplete migration of the testes to the scrotum during embryogenesis. Passage to the inguinal canal begins at 28 weeks gestation. Testicular descent typically occur during the seventh or eighth month in utero. **Risk Factors**: Idiopathic , May involve hormonal, environmental, prenatal health, genetic, mechanical, and or neural factors. Premature birth (30% in preterm infants, 5% full term). Genetic disorders or hormonal imbalances. **Assessment**: Absence of one testis or both testes palpation of scrotum. One or both testicles in location other than the scrotum. This exam is best performed by an examiner who has warm hands. Infant examination: supine, frog leg position or seating on parents\' lap. Older child examination: supine, or sitting a right cross legged position. GU examination to locate testes; attempt to \"milk\" testes into scrotum. Ultrasound if testes are non-palpable. **Referral**: Urology/surgery referral if undescended by 4--6 months. Refer for urology for evaluation if testicle(s) not descended by age 6 months or for boys, \>6 months (corrected for gestational age) with possible newly diagnose (acquire) cryptorchidism. Multiple specialist consultation for evaluation of possible disorders of sex development for all phenotypic newborn boys with bilateral nonpalpable testes. Orchiopexy surgery recommended by 12 months. **Inguinal Hernia** The protrusion of viscera or adipose tissue through the inguinal or femoral canal. Three types have been identified.: Indirect: abdominal tissue passes through an abdominal wall defect into the internal inguinal ring and inguinal canal. Direct: abdominal tissue through the posterior wall of the inguinal canal. Femoral: hernia located inferior to the inguinal ligament and protruding through the femoral ring. 40% are incarcerated or strangulated. Incarcerated: content cannot be replaced into the abdomen. Strangulated: blood supply to the entire bowel is diminished; a surgical emergency. Pain it\'s out of proportion to exam. Erythema, hyper T-shirt, or wound drainage might be present. Reducible: hernia easily replaced into the abdomen, using gentle pressure or may occur spontaneously. **Risk Factors**: Premature birth. 8 -- 10 times more common in men. Age \> 60 years Cigarette smoking: can damage connective tissue. Inheritance: first-degree relative, especially in woman. Family history of hernia. Connective tissue disorder history previous contralateral hernia low body mass index. **Assessment**: A heavy or dragging sensation in the groin or hernia. Painful or painless, swelling, or lump in the groin or into scrotum; may increase with standing or sitting. Bulge might be intermittent and palpable during episodes of increased abdominal pressure (coughing, defecation, micturition, exercise, sexual intercourse). Symptoms worse at the end of the day and relief by laying down or manually reducing the hernia. In woman, bulge might be seeing in the labia majora. Strangulated hernia: colicky abdominal pain, nausea and vomiting, and abdominal distention. Bulge in groin or scrotum, more noticeable during crying or straining. Reducible or irreducible on physical examination. **Treatment:** Surgical repair is typically indicated, particularly if the hernia is painful, enlarging, or causing complications (Dunphy et al., 2022). Educate about signs and symptoms of strangulation and advised to seek immediate medical help if these occur. Do not attempt to reduce a strangulated hernia. Surgical correction (herniorrhaphy) is required if hernia does not resolve spontaneously. **Referral:** Watchful waiting is an acceptable treatment in patients with minimal to no symptoms and with low risk of strangulation. Follow these patients every six months. Refer to surgeon for evaluation. Refer immediately if strangulated. **Follow-up:** Resume preoperative diet. Ambulation as tolerated with no restriction; do not lift more than 5 pounds until clear by surgeon. Avoid straining and other Valsalva maneuvers. Postoperative follow-up is crucial to monitor for complications such as recurrence or infection (Dunphy et al., 2022). **Testicular Torsion** **Findings**: Sudden, severe, unilateral scrotal pain. Scrotal edema, and erythema Firm tender mass that might appear retracted upward No relief of pain with testicular, scrotal elevation Lower abdominal pain Reactive hydrocele High-riding testicle with \"bell-clapper\" deformity. Horizontal lie within the scrotum Nausea and vomiting Testes tenderness is significant Absent cremasteric reflex. Negative Prehn's sign. In children may present a sudden awakening, which scrotal pain Twist score (ranges 0 to 7 points) Testicular swelling -2 points Hard testicle - 2 points Absent cremasteric reflex - 1 point Nausea and vomiting - 1 point High riding testicle - 1 point Testicular pain associated with testicular torsion is usually abrupt on onset. A twist score of \> 4 is a medical emergency. **Treatment**: Non-pharmacological management: Immediate surgical intervention (orchiopexy) within 6 hours. Manual detortion if surgery is not performed within six hours. Bilateral orchiopexy. Surgical exploration and detorsion with orchiopexy or orchiectomy for non-viable testis. Pharmacological management: pain medication antiemetic. **Erectile Dysfunction -** inability to achieve or maintain an erection of sufficient rigidity for sexual performance and or ejaculation. **Screening**: Always consider concurrent medical disorders when a man reports erectile dysfunction. Aging is not a cause. Detailed sexual and medical history, including psychogenic and organic causes. Physical examination (DRE, vascular testing, nocturnal penile tumescence). **Risk Factors**: Vascular - Cardiovascular disease, hypertension, diabetes, smoking, hyperlipidemia, radiation of the pelvis, or retroperitoneum. Respiratory- COPD sleep apnea Neurologic - injuries to spinal cord/brain, Parkinson\'s disease, Alzheimer\'s disease, multiple sclerosis, and stroke. Penile conditions- Peyrone's disease, cavernous fibrosis, penile fracture, epispadias and priapism. Hormonal- hypogonadism hyper or hypothyroidism, hyper or hypercortisolism, hyperprolactinemia. Drug induce: antihypertensive, antidepressant, antipsychotic, antiandrogens, recreational drugs, pain medication, (specially opioids and anticholinergics) 5- alpha reductase inhibitors, antiulcer drugs and alcohol use. Psychogenic- performance related anxiety, PTSD relationship problems, lack of arousal -- attraction in a specific relationship, anxiety, depression, stress. Surgical procedure- radical prostatectomy, retroperitoneal or pelvic lymph node dissection, transurethral resection of the prostate, postoperative disruption in neurologic function. Atherosclerosis, smoking, hypertension, diabetes. Psychological factors (stress, depression). Hormonal imbalances (low testosterone). Age, obesity, diabetes, cardiovascular disease and depression (Dunphy et al., 2022). **Treatment**: Address underlying causes (e.g., lifestyle modification). Phosphodiesterase inhibitors (e.g., sildenafil, tadalafil). Psychotherapy for psychogenic causes. Non-for psychological management - treatment of the underlined condition, psychological support/psychosexual therapy, education about cause, medication dosage adjustment or medication change, penile prosthesis for patient with refractory erectile dysfunction. Vacuum constriction device (27-74% success) vascular surgery when vascular insufficiency is present. Pharmacology management : Sildenafil/Viagra (25mg, 50mg, and 100 mg) Initial dose 50 mg PO 30 minutes to 4 hours before sexual activity. Maximum dose 100 mg PO per dose one time a day. Advise patients to take on an empty stomach if possible. 4 to 8 hours duration. Side effects: avoid concomitant use of nitrates or alpha-blockers. Use with caution impatient with recent MI, CVA. Contraindicated impatience with heart failure. May use a lower starting dose in older adults or patients with diminished renal, or hepatic function. Tadalafil/Cialis (2.5 mg, 5 mg, 10 mg, and 20 mg) Initial dose PRN use: 10 mg PO before sexual activity. Max dose 20 mg PO daily one dose per day; one dose per 72 hours if strong CYP384 use. Daily use initial 2.5 mg PO daily, max 5 mg PO daily; 2.5 mg daily if strong, CYP384 use. Maybe taken without regard of meals. Up to 36 hours duration. Side effects monitoring avoid concomitant use of nitrates. Use caution with alpha-blocker. Use with caution in patients with recent MI or CVA. May use lower starting dose in older adults or patients with diminished renal or hepatic function. Intracavernous injection therapy is a second line treatment. Intracavernosal injection of vasodilators: alprostadil (31-72% success rate). Alprostadil intraurethral suppository (66% success). Hormone replacement, my benefit men with severe hypogonadism or type two diabetes. ### **Sexually Transmitted and Genital Infections** **Gonorrhea --** *Neisseria Gonorrhoeae.* Sexually transmitted disease that produces purulent inflammation of mucous membranes. Can be asymptomatic in early infection, especially among women. Untreated gonorrhea infection can cause significant complications. **Testing**: nucleic acid amplification test (NAT) is most sensitive and specific. Appropriate and sensitive for screening Urogenital, rectal or pharyngeal infection. Samples can be self-collected by the patient with similar sensitivity and accuracy. Should not be used to diagnose infections in sexual assault, neonatal infection, other body fluids (CSF, blood, joint aspirate), or anti-microbial acceptability testing AST. Diagnosis of infection at specific site must occur by testing secretions from specific sites ( rectum, pharynx, cervix, or urethra, eye, scalp wound). Testing must be done with separate sampling and is indicated based on sexual practices and clinical symptoms. Due to similarities in etiology and presentation testing for C. Trachomatis at the same time, from all relevant sites, is recommended. Gonococcal culture and NAAT test. First urine of the day. Female: endocervical swab Male: urethral swab All sex partners in the past 60 days should be tested for infection. If no sex partners in the last 60 days, most recent partner should be tested for infection. NAAT and AST exam should be done concurrently. Test of cure is not necessary except: with potential treatment failure, in pregnancy, after treatment of antibiotic resistant organism, always retest with NAAT culture and AST 7-14 days after treatment. **Treatment**: antibiotics Ceftriaxone 250mg IM for one dose PLUS Azithromycin 1g PO x 1 dose. Alternative therapy (less effective): Cefixime 400 mg orally for one dose PLUS Azithromycin 1g PO x 1 dose. If cephalosporin allergy: gemifloxacin 320 mg orally in a single dose PLUS Azithromycin 2 g PO x 1 dose. Follow CDC guidelines for complicated or refractory gonorrhea. Consider EPT (Expedited Partner Treatment). **Retesting:** Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated; scheduling the follow-up visit at the time of treatment is encouraged. If retesting at 3 months is not possible, clinicians should retest whenever persons next seek medical care \ 20 WBC per high powered field. Culture: not typically use secondary to cost; technical expertise required. **Treatment**: Non-pharmacological management: Education about serious sequelae of C. trachomatis. Abstinence for seven days after partner completion of treatment. Evaluate and treat sexual partners. All sexual contact within the past 60 days should undergo testing. Expedite partner treatment. Sexual abuse should be considered in any child with confirmed chlamydia after the neonatal period. Report to local health department. In woman at risk, screening during third trimester (\< 25 years old, recent new sexual partner, more than one sexual partner). **Pharmacologic management:** Treatment is started after results are known, but if clinical suspicion is high, treatment can commence before test results are known. For adult: first line is a Azythromycin 1 g PO single dose. OR Doxycycline 100 mg orally 2 times/day for 7 days OR doxycycline for 10 to 14 days if epididymis involve or for pelvic inflammatory disease. Second line Levofloxacin 500 mg PO daily for seven days OR ofloxacin 300 mg PO BID for seven days. Erythromycin base 500 mg PO QID for seven days or erythromycin ethylsuccinate 800 mg QID for seven days if patient unable to take doxycycline. Pregnancy: amoxicillin 500 mg PO TID for seven days. Treat with Azythromycin , erythromycin base or amoxicillin. Tetracycline and quinolones are contraindicated during pregnancy. **Signs and Symptoms**: Chlamydia is the most common STI, highest rates under age 25, often asymptomatic, screen under age 25 annually, new sex partner, more than 1 partner, recent partner with STI. If symptomatic: Burning upon urination, pain during sex, lower belly pain, abnormal, smelly discharge, bleeding between periods. **Woman:** often asymptomatic 85%, mucopurulent cervicitis, edema, congested, friable cervix, vaginal discharge and or vaginal bleeding, breakthrough bleeding or spotting, discharged from Barltholin glands when milked, cervical motion tenderness. Dysuria/pyuria, urethritis, pelvic pain/ salpengitis. Higher risk of premature rupture of membranes and preterm delivery during pregnancy, proctitis. **Male:** Dysuria, proctitis, epididymitis, prostatitis, penile discharge. **Herpes -** common sexually transmitted viral infection, characterized by incurable cutaneous, or mucous membrane alterations that are often recurring. Even when no signs of infection are present and genital herpes is easily spread to sexual partners. **Testing**: PCR assays for HSV DNA or IGG testing which is often included in an STI panel. Many point of care test available. Viral culture by on roofing vesicle for fluid culture (ask lab about specific testing tube -- swap); lower sensitivity and specificity HSV PCR higher sensitivity than viral culture. Type-specific cytologic essays (usually +4 to 6 weeks after onset of symptoms.) seroconversion can take up to six months; my repeat testing in six months if initially IgG negative. False positive may occur; repeat testing in three months if low positive. Tzanck smear. ELISA, Syphilis Serology. **Treatment**: Non-pharmacological management: counseling, natural course of disease, asymptomatic viral, shedding, potential for recurring episodes, sexual transmission, implications for pregnancy, counseling for discordant couple, cool conferences with Burow's solution. sitz bath, ice packs to lesion area, NSAIDs or acetaminophen for pain, good hygiene, a boy sexual contact during symptomatic periods, for 48 hours after symptom resolve, and during prodromal symptoms. Use condoms during all sexual exposure to decrease risk of transmission when asymptomatic. Avoidance of triggers for recurrence infections when possible. Pharmacological management: treatment regimen, determined by infection type or purpose: primary infection, recurrent episode or deceased suppression. Per CDC guidelines, treatment is with nucleotide analogs that selectively inhibit replication of HSV one, HSV2 and Varicella Zoster virus. PRIMARY treatment: Acyclovir 400mg TID 7-10 days OR Acyclovir 200mg po x 5 days for 7/10 days OR Famciclovir 250 mg TID for 7- 10 days OR Recurrence: acyclovir 800 mg PO BID for five days OR acyclovir 400 mg PO TID for 5 to 10 days OR acyclovir 800 mg PO TID for two days or famciclovir 125 mg POBID for five days SUPPRESSIVE -- azyclovir 400 mg PO BID or famciclovir 250 mg PO BID up to one year. **Signs and Symptoms**: Many people have no symptoms while shedding the virus. Primary infection might be proceeded by non-primary first episode infection (few lesions and less systemic symptoms and primary infection.) initial infection may be asymptomatic, painful ulceration, hyperesthesia, headache, malaise, myalgia, dysuria, lymphadenopathy, localized pruritus. Recurrent infections: prodrome of pain, burning, and or paresthesia over area of eruption. Burning genital, pain, lesion (vesicular or ulcerative) that resolved within 7 to 10 days. **Bacterial Vaginosis -** Gardnerella Vaginalis **Testing**: To be diagnosed, need at least three clinical criteria: Thin white discharge, Clue cells (seen on Wet Mount Test when Potassium hydroxide (KOH) is added), Ph\>4.5, Fishy odor with the "whiff test" **Treatment**: Metronidazole 500mg orally BID for 7 days, OR metronidazole gel 0.75% one full applicator (5g) intravaginally QD 5 days OR Clindamycin cream 2% one fill applicator (5g) intravaginally at bedtime for 5 days **Signs and Symptoms** Thin, grayish-white discharge with a fishy odor, especially after intercourse. **Trichomonas** **Testing**: **Gold standard -- Affirm (checks for BV, yeast, trich), w**et mount -\> low sensitivity, **Gold standard -- Affirm (checks for BV, yeast, trich)** **Treatment**: Metronidazole 2g single dose OR tinidazole 2g single dose OR Metronidazole 500mg BID x 7 days **Signs and Symptoms**: Vaginal discharge that is thin, frothy, and has a foul or fishy smell , itching or burning of the genitals or inner thighs, pain or discomfort when urinating or during sex , redness or swelling of the vulva or labia , symptoms can appear within 5 to 28 days of exposure, but some people don\'t develop symptoms until much later. Most people with trich don\'t have any symptoms. **HIV** **Testing** HIV antibodies and/or RNA test (ELISA and confirmatory Western blot, or rapid tests). Antiretroviral therapy (ART), consisting of a combination of at least three antiretroviral drugs, typically from different classes (e.g., NRTIs, NNRTIs, protease inhibitors). **Signs and Symptoms** Acute retroviral syndrome (ARS) includes fever, sore throat, rash, swollen lymph nodes, and myalgia 2-4 weeks after exposure. Asymptomatic in the early stages but can progress to AIDS without treatment. **PID** **Testing** Clinical diagnosis based on pelvic tenderness, cervical motion tenderness, and/or positive tests for gonorrhea or chlamydia. **Treatment** Empiric, antibiotic therapy for broad coverage, including ceftriaxone (for gonorrhea) and doxycycline (for chlamydia). Hospitalization may be required for severe cases. **Signs and symptoms** lower abdominal/pelvic pain, fever, abnormal vaginal discharge and dyspareunia. Severe cases may result in turbo-ovarian abscesses or infertility. **PCOS:** a complex endocrine condition characterized by hyperandrogenism, adulatory dysfunction, and or polycystic ovaries. **Testing**: Hyperandrogenism: Exclusion of other causes: TSH: normal prolactin: normal 7 hydroxy progesterone FSH or LH age to evaluate for premature ovarian failure Evaluate for catching syndrome 24hour urine for cortisol excretion test Ultrasound Quantify hirsutism using the Ferriman -- Gallwey score Labs to monitor for cardiometabolic risk Glucose tolerance test Lipid profile **Treatment**: Nonpharmacological treatment Lifestyle modification Weight loss is first line intervention, if overweight Education Screening for management of behavioral health conditions Acupuncture Hair removal therapy Bariatric surgery Monitor for cardio metabolic risk at least annually Blood pressure, consider ambulatory BP monitoring Waist circumference BMI Lab monitoring at diagnosis and every two years in patients who are overweight, patient at high risk for insulin resistance Lipid Glucose tolerance test Pharmacological management: Pharmacological treatment is generally aimed at the management of menstrual disorder and hyperandrogenism associated with PCOS. Combined oral contraceptive for management of oligomenorrhea. First line treatment for PCOS. Mechanism of action: Inhibit ovulation through negative feedback on pituitary tropic release. FDA indication: contraception, select formulations also indicated for acne bulgaris, premenstrual dysphoric disorder. Progesterone with higher antiadrenergic properties might be more beneficial to woman with PCOS (desogestrel, norgestimate, and progestin). Estrogen (ethinyl estradiol) and progesterone: Norethindrone, drospirenone, levonorgestrel, desogestrel, norgestrel, ethynediol diacetate (pills, patch, ring). Progesterone-only method for management of oligomenorrhea. Mechanism of action: transform a proliferative endometrium into a secretory endometrium, inhibit secretion of pituitary gonadotropins. Medroxyprogesterone (Depo-Provera) Estonogestrel (Nexplanon), Levonogestrel (Kyleena, Liletta, Mirena, Skyla). Biguanide for management of insulin sensitivity. Mechanism of action decreases hepatic glucose production, intestinal absorption of glucose; improves insulin sensitivity; in PCOS, reduces hyperinsulinemia, reduces serum testosterone, increases pregnancy rates, improve metabolic syndrome symptoms. Metformin or Glucophage 500 mg twice a day may increase weekly. Monitor hemoglobin A1c at least every six months, CBC, renal function, at least annually, B12 every three years. **Signs and Symptoms:** Common feature is hypersecretion of androgens. In adult women 2 of 3 must be present for diagnosis: Hyperandrogenism Acne Hair statism (male pattern terminal hair growth) Thinning, scalp hair, alopecia Clitoral hypertrophy Deeping off voice Ovulatory dysfunction Oligoovulation or anovulation Amenorrhea or oligomenorrhea Ovarian cyst Weight gain Acanthosis nigricans Polycystic ovaries on ultrasound **Infertility** ### **Women's Health** **Menstrual Health** **Amenorrhea and Irregular Vaginal Bleeding**: Primary or secondary amenorrhea; bleeding irregularities often point to underlying hormonal imbalances or structural issues. **Primary Amenorrhea:** Complete absence of a menstrual period by the age of 16 in a person with normal sexual development.  **Secondary Amenorrhea:** The sudden cessation of menstrual periods for several months in a person who previously had regular cycles PCOS is most common cause of Secondary Amenorrhea **Menstrual Cycle**: Phases of the cycle---menstrual, follicular, ovulatory, and luteal phases---each with its hormonal shifts. The rise and fall of your hormones trigger the steps in your menstrual cycle. Your hormones cause the organs of your reproductive tract to respond in certain ways. The specific events that occur during your menstrual cycle are: **The menses phase: **This phase begins on the first day of your period. It\'s when the lining of your uterus sheds through your vagina if pregnancy hasn't occurred. Most people bleed for three to five days, but a period lasting only three days to as many as seven days is usually not a cause for worry. **[The follicular phase](https://my.clevelandclinic.org/health/body/23953-follicular-phase):** Less consistent phase of the cycle. This phase begins on the day you get your period and ends at ovulation (it overlaps with the menses phase and ends when you ovulate). During this time, the level of the hormone estrogen rises, which causes the lining of your uterus (the endometrium) to grow and thicken. In addition, another hormone --- [follicle-stimulating hormone (FSH)](https://my.clevelandclinic.org/health/articles/24638-follicle-stimulating-hormone-fsh) --- causes follicles in your ovaries to grow. During days 10 to 14, one of the developing follicles will form a fully mature egg (ovum). The follicular phase of the menstrual cycle is considered less consistent compared to the luteal phase, which tends to be relatively stable in length for most women; meaning the length of the follicular phase can vary more from cycle to cycle while the luteal phase usually stays around 14 days. **[Ovulation](https://my.clevelandclinic.org/health/articles/23439-ovulation):** This phase occurs roughly at about day 14 in a 28-day menstrual cycle. A sudden increase in another hormone --- [luteinizing hormone (LH)](https://my.clevelandclinic.org/health/body/22255-luteinizing-hormone) --- causes your ovary to release its egg. This event is ovulation. **The luteal (secretory) phase:** This phase lasts from about day 15 to day 28. Your egg leaves your ovary and begins to travel through your fallopian tubes to your uterus. The level of the hormone progesterone rises to help prepare your uterine lining for pregnancy. If the egg becomes fertilized by sperm and attaches itself to your uterine wall (implantation), you become pregnant. If pregnancy doesn't occur, estrogen and progesterone levels drop and the thick lining of your uterus sheds during your period. **PCOS** **Diagnosis**: Based on symptoms like irregular periods, hyperandrogenism, and polycystic ovaries on ultrasound. Common feature is hypersecretion of androgens. In adult women 2 of 3 must be present for diagnosis: Hyperandrogenism, Oligoovulation or anovulation, Polycystic ovaries on ultrasound **Management**: Lifestyle adjustments, hormonal contraceptives, and insulin-sensitizing medications. **Contraception**: Discussion of options from hormonal (pills, IUDs) to barrier methods, benefits, and risks. **Breast Cancer Screening**: Mammograms and breast self-exams; follow current guidelines for age and risk factors. Manual exam in every visit. 40 and over every two years for mammograms, but also encourage self exam and perform manual exam at every wellness visit **Lactation and Postpartum Care** **Mastitis**: Recognize symptoms like breast pain, redness, and fever; treat with antibiotics. **Breastfeeding Support**: Guidelines on feeding frequency, latch techniques, and troubleshooting. **Preeclampsia: Early sign of preeclampsia what gestational week you see preeclamsia** Management of blood pressure, regular monitoring for proteinuria, and signs of worsening condition. **Labor**: Stages and physiological changes; recognizing signs of labor onset. **RhoGAM**: Administration to Rh-negative mothers to prevent alloimmunization. **UTI**: Prevention, common symptoms like dysuria, frequency, and urgency, and appropriate antibiotic treatment. **Care of the Pregnant Patient** **Gestational Diabetes**: Screening at 24-28 weeks, management with diet, exercise, and insulin if needed. **Pregnancy Complications**: 10 - 20% of pregnant patients. **Early Pregnancy loss:** Within the first 13 weeks of pregnancy, miscarriage spontaneous abortion (SAB). If suspected loss referral to OBGYN or midwife. After 13 weeks GYN surgeon for possible intervention. Beta HCG after SAB follow levels until 0. Advice patient not to try to conceive until results are 0. 80% loss happens in first semester 1/5 women will miscarriage at some point. Complete AB - at some point that may actually be much higher as many women may have a late period and even a positive home pregnancy test, but we\'ll go onto abortion shortly after and assume they were just having a late period and a false positive pregnancy test completed. Gestational trophoblastic disease (GTD). Molar pregnancy, intermitting spotting, grossly enlarged uterus, extreme N/V, requires D&C referred to GYN, pt not to become pregnant withing 6 months, suspect of reoccurrence with next pregnancy. Placenta previa. provided consult is recommended. 1 in 4 women may experience bleeding during pregnancy. Common during intercourse in the first half of pregnancy. Light bleeding with no pain least risk of SAB. R/O any immediate or life-threatening concerns more than 2 pads per hour for more than 2 hours evaluate if pt is hemodynamically stable and referred as needed. Beta HCG -- a test that uses a number to associate gestational age. May repeat every 2-3 days, an increase in HCG levels indicates a viable pregnancy. Helpful tool in evaluating early bleeding specially before 6 weeks. Ultrasound Gestational sac can be seen as early as 4-5 weeks, yolk sac been seen at 5 weeks. Fetal heartbeat and cardiac activity after 6-7 weeks. **Second & Third Trimester Bleeding**: Emphasizes no vaginal exams and includes necessary lab tests like CBC and Type and Screen for Rh-negative cases. **Preterm Labor and Birth** : Identified as a leading cause of neonatal mortality with social and racial disparities impacting risk. Prevention includes nutrition, substance cessation, and adequate spacing between pregnancies. **Hypertensive Disorders** : Covers chronic hypertension, gestational hypertension, preeclampsia, and eclampsia, stressing accurate blood pressure measurement and early screening. Key symptoms include visual disturbances, RUQ pain, and edema. **Hyperemesis Gravidarum**: Defined by symptoms like excessive nausea, likely due to high hCG, estrogen, and thyroid levels. Management strategies are outlined, including IV fluids as needed. **Hematologic & Thromboembolic Disorders**: Focuses on anemia, blood type issues, and specific conditions like Sickle Cell Disease and Thalassemia. Thrombocytopenia and folate deficiency are also noted. **Dermatologic Disorders**: Common conditions include PUPP, PG, and ICP, with reference to pre-existing conditions that may flare during pregnancy. **Group B Strep (GBS)**: Screening recommendations and treatment during labor to prevent neonatal mortality are discussed. **STIs in Pregnancy**: Regular screening and management, emphasizing treatment protocols and prevention strategies. **Medications During Pregnancy** **Depression:** Selective serotonin reuptake inhibitors (SSRIs). These are often the first-line treatment for depression during pregnancy because they have minimal side effects and have been studied extensively. Some examples include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft). However, SSRIs can cause adaptation syndrome in newborns, which is similar to withdrawal symptoms **Diabetes: From the ADA:** Insulin is the traditional first-choice drug for blood glucose control during pregnancy because it is the most effective for fine-tuning blood glucose and it doesn't cross the placenta. Therefore, it is safe for the baby. Insulin can be injected with a syringe, an insulin pen, or through an insulin pump. All three methods are safe for pregnant women. **High blood pressure: Studies show that three blood pressure medications are generally safe for treating high blood pressure in most pregnancies:** [Methyldopa](https://www.goodrx.com/methyldopa/what-is) has the longest and most reassuring track record of safety in pregnancy. This medication relaxes the blood vessels, which lowers blood pressure. [Labetalol](https://www.goodrx.com/labetalol/what-is) slows your heart rate, which lets your heart relax. [Nifedipine](https://www.goodrx.com/nifedipine-er-procardia-xl/what-is) only needs to be taken once a day in the extended-release form. **Pre- and Post-Pregnancy Follow-up**: Importance of regular check-ups to monitor both maternal and fetal health. **Ectopic Pregnancy**: **Symptoms:** Abdominal pain, vaginal bleeding, amenorrhea; may also include dizziness, fever, and syncope. Sever abdominal pain and bleeding between week 5- 8. Emergency referral. 50% of patients that have an ectopic pregnancy will have: Abdominal pain, vaginal bleeding, amenorrhea. May also present with symptoms common to early pregnancy (nausea, breast fullness) Dizziness, fever, weakness, flu like symptoms, vomiting, syncope, cardiac arrest. Any of the following signs and symptoms are an EMERGENCY Abdominal rigidity, involuntary guarding, severe tenderness, evidence of hypovolemic shock (examples -- orthostatic blood pressure changes, tachycardia) **Diagnostics:** Ultrasound imaging to visually determine location and serial quantitative beta-hCG. **Treatment:** Methotrexate intramuscular for non-ruptured hemodynamically stable cases. THIS IS NOT FDA APPROVED but has been endorsed by the ACOG, it avoids surgery, hcg values must be less than 1500. Surgical intervention if unstable. **Group B Strep Screening and Treatment**: Screening at 35-37 weeks gestation; antibiotics during labor for positive cases. **Naegele's Rule**: Method to estimate the due date---add one year, subtract three months to the LMP and add seven days and a year. **Genetic Screening**: Understanding indications and types, such as noninvasive prenatal testing (NIPT). **Family Planning**: Counseling on options for future pregnancies and spacing. - **ideal pregnancy spacing:** **Explain that waiting 18-24 months between pregnancies is generally considered optimal for maternal and child health, with potential benefits like reduced risk of preterm birth, low birth weight, and infant mortality. ** - **Individualized approach:** **Tailor the counseling to each person\'s unique circumstances, including age, health status, lifestyle factors, and family planning goals. ** - **Contraceptive method options:** - **Long-acting reversible contraception (LARC): Highlight the effectiveness and convenience of methods like IUDs and implants, which can be particularly suitable for individuals desiring long-term birth control without needing to remember daily medication. ** - **Hormonal methods: Discuss benefits and potential side effects of birth control pills, patches, and injections, considering factors like menstrual regularity and ease of use. ** - **Barrier methods: Explain the role of condoms in preventing sexually transmitted infections (STIs) alongside pregnancy prevention. ** - **Natural family planning: Discuss the limitations and potential for user error associated with fertility awareness methods like ovulation tracking and withdrawal. ** - **Preconception counseling:** **Encourage individuals planning to become pregnant to discuss preconception health optimization, including folic acid supplementation, healthy lifestyle habits, and addressing any medical conditions that might impact pregnancy. ** - **Postpartum family planning:** **Emphasize the importance of discussing contraception options soon after delivery to ensure timely initiation of birth control if desired. ** **Important considerations:** - **Medical history:** **Evaluate potential health risks associated with different contraceptive methods based on the individual\'s medical history, including conditions like hypertension, breastfeeding, or smoking. ** - **Access to care:** **Discuss the availability and cost of different contraceptive methods in the individual\'s area. ** - **Partner involvement:** **Encourage open communication with partners regarding family planning decisions and contraceptive choices. ** **Management of Pregnant Patients in Primary Care**: Addressing primary care concerns while balancing pregnancy-related health needs. No live vaccines MMR, Varicella, Shingles, live flu. **Screening Tests:** Various tests are conducted based on gestational age, including first-trimester screening, cell-free DNA testing, and Group B strep testing. **Gestational Diabetes:** a complex metabolic disorder in which pregnancy related insulin resistance results in a higher blood glucose levels. Current screening guidelines typically lead to diagnosis between 24- and 28-weeks\' gestation. Woman whose diabetes is identified in the first trimester should be diagnosed with overt or T2DM not his stational diabetes. Nonpharmacological management: major component of managing his stational diabetes is patient education about diet, exercise and blood glucose self-monitoring. Caloric requirements: normal BMI 30 to 35 kcal per kilogram per day. Greater than 90% of normal BMI 30 to 40 kcal per kilo kilogram per day. Greater than 120% of normal BMI 24 kcal per kilogram per day. Low carbohydrate, diet, complex, high fiber, carbohydrate, decrease refined carbohydrate. Exercise 30 to 60 minutes of moderate intensity exercise at least three times per week or 30 minutes of moderate intensity, exercise daily. Glucose monitoring after beginning dietary recommendations to confirm glycemic control and determine medication choice. Insulin therapy is standard for pharmacological therapy for gestational diabetes. Screening protocols at 24-28 weeks and includes a glucose tolerance test. Management in primary care highlights the adverse outcomes and weight gain recommendations for obese patients. **Puerperium:** Postpartum period where the body adjusts and returns to its non-pregnant state, which includes uterine involution and gradual muscle tone recovery. Exam review from Dr. Hammond **Must review!** **Herina inguinal, ventral, umbilical: indirect hernia How they present:** **An inguinal hernia typically presents as a bulge in the groin area, often noticeable when standing or straining, while a ventral hernia appears as a bulge anywhere on the abdominal wall, and an umbilical hernia shows as a visible swelling around the belly button; an indirect inguinal hernia specifically presents as a bulge in the groin that can sometimes extend into the scrotum in men, often feeling like a soft lump that worsens with activity and can be pushed back in when lying down.** **Key points about each type of hernia presentation:** **Inguinal hernia:** **Visible bulge in the groin area** **Feeling of pressure or weakness in the groin** **Discomfort or pain when bending, lifting, or coughing** **May extend into the scrotum in men** **Ventral hernia:** **Bulge on the abdomen, often along the midline** **May be visible or only palpable depending on the size and location** **Pain or discomfort that worsens with activity** **Umbilical hernia:** **Visible bulge at the belly button** **May be more prominent when straining or crying (in infants)** **Often painless, especially in infants** **Important considerations:** **Indirect inguinal hernia:** **This specific type of inguinal hernia occurs when the bowel protrudes through the inguinal ring, following the path of the spermatic cord in males, which is why it can extend into the scrotum.** **Symptoms that may indicate a complication (incarceration):** **Severe pain** **Nausea and vomiting** **Inability to reduce the bulge** **Redness and swelling at the hernia site** **Prehns Sign:** **Prehn\'s sign is a clinical finding that helps clinicians determine whether testicular pain is caused by [epididymitis](https://www.osmosis.org/learn/Epididymitis) or [testicular torsion](https://www.osmosis.org/learn/Testicular_torsion). A positive Prehn\'s sign, characterized by pain relief from the maneuver, is indicative of epididymitis, or the inflammation of the epididymis (i.e., duct running behind the [testes](https://www.osmosis.org/learn/Testicular_cancer:_Nursing)). Conversely, a negative Prehn\'s sign is characterized by an exacerbation of pain and indicates testicular torsion, or the [rotation](https://www.osmosis.org/learn/Anatomical_terminology) of the [testicles](https://www.osmosis.org/learn/Testicular_cancer:_Nursing) around the [spermatic cord](https://www.osmosis.org/learn/Anatomy_of_the_inguinal_region), resulting in the obstruction of [blood flow](https://www.osmosis.org/learn/Cardiovascular_system_anatomy_and_physiology) to the [testicle](https://www.osmosis.org/learn/Testicular_cancer:_Nursing). Testicular torsion is considered a medical emergency and requires immediate medical attention.** **Cremasteric reflex:** a superficial reflex when the inner thigh is stroked, causing the cremaster muscle to contract and pull the testicle up. Absent in testicular torsion. **Scrotal mass and hydrocele when will you have the patient re assess if a baby we watch but how long will you re assess:** **A \"scrotal mass\" refers to any lump or bulge felt in the scrotum, while a \"hydrocele\" is a specific type of scrotal mass where fluid accumulates within the sac surrounding the testicle, causing painless swelling in the scrotum; essentially, a hydrocele is a fluid-filled collection within the scrotum, considered a benign scrotal mass. ** **Key points to remember:** - **Scrotal mass:** **A general term for any lump or bulge in the scrotum, which can be caused by various conditions including a hydrocele, testicular cancer, varicocele, epididymitis, or a cyst. ** - **Hydrocele:** **A painless swelling in the scrotum due to fluid buildup within the tunica vaginalis, the sac surrounding the testicle. ** **Important considerations:** - **Diagnosis:** **To determine the cause of a scrotal mass, a doctor will perform a physical examination, including palpating the scrotum, and may order further tests like an ultrasound to differentiate between a hydrocele and other potential causes. ** - **Symptoms:** **A hydrocele typically presents as a smooth, fluid-filled swelling in the scrotum that may change size throughout the day, while other scrotal masses could be associated with pain or discomfort. ** - **Treatment:** **Most hydroceles in children resolve on their own, while larger or symptomatic hydroceles in adults may require surgical drainage of the fluid. A baby with a scrotal mass or hydrocele should be reassessed by a doctor if the swelling is large, firm, painful, or does not resolve on its own by the time the baby is around one year old; if you notice any significant worsening or new symptoms, contact your pediatrician immediatel** **Cryptorchidism and when to do an orchiopexy::** **An orchiopexy for cryptorchidism (undescended testicles) is typically recommended when a child\'s testicle(s) haven\'t descended into the scrotum by around 6 months of age, with most experts suggesting surgery should be performed ideally before the child turns 1 year old to minimize the risk of future fertility issues and potential testicular cancer development;. ** **Key points about cryptorchidism and orchiopexy:** - **What is it?:** **Cryptorchidism is a condition where one or both testicles haven\'t descended into the scrotum naturally. ** - **Why surgery is needed:** **Early surgical intervention through an orchiopexy is recommended to reposition the undescended testicle(s) into the scrotum, reducing the risk of infertility and potential testicular cancer later in life. ** - **Ideal timing:** **Most medical professionals advise performing an orchiopexy between 6 months and 1 year of age. ** - **Reasons for early surgery:** - **Fertility concerns: The longer an undescended testicle remains outside the scrotum, the higher the potential for impaired sperm production. ** - **Cancer risk: Some studies suggest a slightly increased risk of testicular cancer associated with undescended testicles, which can be lowered by early surgical correction** **Erectile Dysfunction, what medication is used, when is it contraindicated, what is common cause of ED?** **Erectile dysfunction (ED) can have many causes, including physical and psychological factors: ** - **Medical conditions** **High blood pressure, high cholesterol, diabetes, cardiovascular disease, prostate problems, multiple sclerosis, spinal cord injuries, and nerve damage ** - **Medications** **Antidepressants, antihistamines, and medications for high blood pressure, pain, or prostate conditions ** - **Substance use** **Tobacco use, drug use, and heavy drinking ** - **Psychological conditions** **Depression, anxiety, performance anxiety, stress, relationship problems, lack of sexual knowledge, past sexual problems, and past sexual abuse ** - **Other factors** **Being overweight, chronic sleep disorders, and injuries that damage nerves or arteries ** - **Aging** **Although you are more likely to develop ED as you age, aging does not cause ED ** **ED is defined as having trouble getting or keeping an erection that\'s firm enough for sex. Occasional ED is usually caused by stress, tiredness, or drinking too much alcohol, and it\'s nothing to worry about** **Medications for ED and contraindications:** **There are several oral medications that can treat erectile dysfunction (ED), including:** - **Sildenafil (Viagra): The first FDA-approved ED medication in 1998. It\'s effective for 69% of people. ** - **Tadalafil (Cialis): Approved by the FDA in 2003. ** - **Vardenafil (Levitra, Staxyn): Approved by the FDA in 2003. ** - **Avanafil (Stendra): Approved by the FDA in 2012. ** **These medications are all phosphodiesterase type 5 (PDE5) inhibitors, which work by relaxing the penile erectile tissues during sexual stimulation. ** **Oral medications for ED might not be safe for everyone. They can be dangerous or ineffective if you\'re also taking:** - **Nitrate medicines, which are often prescribed for chest pain** - **Alpha-blocker medicines, which are commonly prescribed for an enlarged prostate** - **Medicines that affect the CYP3A4 enzym** **BPH s/s how it present and what is the tx plan** **Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland that can cause a variety of symptoms:** - **Frequent urination, especially at night** - **A weak urine stream** - **Leaking or dribbling of urine** - **Difficulty starting urination** - **Pain after ejaculating or while urinating** - **Pee changes color or smells ** **Symptoms usually begin after age 45, but some men have no symptoms. Treatment is only necessary if symptoms become bothersome. Treatment options include: ** - **Lifestyle changes** **Limit fluids before bedtime or going out, and reduce consumption of caffeine and alcohol. You can also try pelvic floor muscle training. ** - **Medications** **Options include alpha blockers, 5-alpha-reductase inhibitors, and phosphodiesterase-5 inhibitors. ** - **Surgery** **Options include greenlight laser surgery (PVP) and robotic waterjet treatment. ** - **Watchful waiting** **This may be an option if symptoms are minor. ** **You should contact your provider right away if you have:** - **Less urine than usual** - **Fever or chills** - **Back, side, or abdominal pain** - **Blood or pus in your urine** **Scrotal pain and swelling Dx test :** **To diagnose scrotal pain and swelling, the primary diagnostic test is a scrotal ultrasound with Doppler imaging which can effectively identify the cause, particularly differentiating between testicular torsion (decreased blood flow) and epididymitis (increased blood flow) by assessing blood flow in the affected area; a physical exam is also crucial, and depending on the situation, a urine test may be needed to check for infection.** **Key points about diagnosing scrotal pain and swelling:** **Physical exam:** **A doctor will perform a thorough physical examination of the scrotum, checking for tenderness, lumps, and swelling.** **Ultrasound with Doppler:** **This imaging test is considered the gold standard for diagnosing the cause of scrotal pain and swelling, as it can visualize the internal structures of the scrotum and assess blood flow.** **Urine analysis:** **A urine test can be helpful to check for signs of infection, which could be related to epididymitis.** **Blood tests:** **In some cases, blood tests may be ordered to look for signs of inflammation or infection.** **Conditions that can cause scrotal pain and swelling:** **Testicular torsion: A medical emergency where the spermatic cord twists, cutting off blood supply to the testicle.** **Epididymitis: Inflammation of the epididymis, often caused by a bacterial infection.** **Orchitis: Inflammation of the testicle itself, usually due to infection.** **Hydrocele: Fluid collection around the testicle** **Spermatocele: A benign cyst filled with sperm fluid** **Varicocele: Enlarged veins in the scrotum** **Squamous cell ca of the penis which patient is at risk** **Penile squamous cell carcinoma (SCC) is the most common type of penile cancer, accounting for about 95% of cases. It\'s relatively rare in the United States, but more common in developing countries: ** - **Symptoms** **Early tumors can be small and look like abrasions or callused skin. They can also appear as a raised, reddened maculopapule, ulcer, or exophytic papillary tumor. ** - **Diagnosis** **A biopsy is required to diagnose penile SCC, and should include normal skin for comparison. A doctor may also feel the lymph nodes in the groin for swelling. ** - **Treatment** **Early-stage penile SCC is usually curable. Treatments include: ** - **Mohs micrographic surgery ** - **Sentinel lymph node biopsy, which involves removing the first lymph node to receive lymphatic drainage from the tumor** **RISK FACTORS:** **Human papillomavirus (HPV)**: A virus that\'s passed through sexual contact, including oral sex.  **Uncircumcision**: Circumcision may help prevent HPV infection. However, there\'s little evidence that adult circumcision reduces the risk of penile cancer.  **Phimosis**: A condition where the foreskin can\'t be pulled back over the glans.  **Smoking**: Current cigarette smokers have an increased risk of penile cancer.  **Poor hygiene**: Not washing the penis frequently or thoroughly can increase the risk of smegma, a buildup of fluids that can collect under the foreskin.  **Age**: Being 60 years or older increases the risk of penile cancer.  **Other penile conditions**: Rash, tearing, and inflammation of the penis may be risk factors **Testicular torsion DX test and how to treat** **A diagnosis of testicular torsion is typically made through a physical examination by a doctor, often accompanied by a Doppler ultrasound to confirm blood flow issues in the affected testicle; the primary treatment is immediate surgery to untwist the spermatic cord and secure the testicle in place, as testicular torsion is considered a medical emergency requiring prompt action to maximize the chance of saving the affected testicle. ** **Key points about testicular torsion diagnosis and treatment:** **A negative Prehn\'s sign is a key indicator of testicular torsion, a medical emergency that requires immediate diagnosis and treatment:** - **Prehn\'s sign: A test that involves lifting the scrotum to assess pain changes. A negative Prehn\'s sign indicates that lifting the scrotum makes the pain worse, which is a sign of testicular torsion. A positive Prehn\'s sign indicates that lifting the scrotum relieves pain, which is a sign of epididymitis.** - **Symptoms:** **Sudden, severe pain in the scrotum, swelling, nausea, vomiting, and sometimes the testicle appearing higher than normal or at an unusual angle. ** - **Physical examination:** **The doctor will carefully examine the scrotum, checking for tenderness, swelling, and the position of the affected testicle. ** - **Doppler ultrasound:** **This imaging test is used to assess blood flow to the testicle, which can be significantly reduced in cases of torsion. ** - **Treatment:** - **Immediate surgery: The primary treatment is surgical intervention to untwist the spermatic cord and usually fix the testicle to the scrotum to prevent future torsion (orchiopexy). ** - **Time is critical: The best chance of saving the testicle is within 4-6 hours of the onset of symptoms. ** - **Potential complications: If left untreated for too long, the affected testicle may need to be removed (orchiectomy** **Pyrones disease presentation and pathological content how it will present :** **Peyronie\'s disease is a chronic condition that causes a significant bend in the penis during an erection, sometimes along with pain. It can make it difficult to get or maintain an erection, and can prevent vaginal intercourse** **For men with stable, mild curvature (≤30 degrees) who have satisfactory erectile function, observation is an acceptable option In cases of worsening curvature or sexual dysfunction medical and/or surgical management (removal of plaque) Click to edit Master title style** ** For men with stable, mild curvature(≤30 degrees)who have satisfactory erectile function ,observation is an acceptable option** ** In cases of worsening curvature or sexual dysfunction medical and/or surgical management (removal of plaque)** ** Oral pentoxifylline(vasodilator and anti-inflammatory) best initial treatment within three months of onset** ** In men who are bothered by penile deformity of\>3 months' duration may use intra lesional injection with collagenase** ** Surgical management is indicated for patients whose Peyronie\'s disease has persisted for rmore than12 months, is refractory to medical treatment, and is associated with a penile deformity compromising sexual function.** **Symptoms of bladder cancer:** **Bladder cancer signs and symptoms may include:** - **Blood in urine (hematuria), which may cause urine to appear bright red or cola colored, though sometimes the urine appears normal and blood is detected on a lab test** - **Frequent urination** - **Painful urination** - **Back pain** **When to see a doctor** **If you notice that you have discolored urine and are concerned it may contain blood, make an appointment with your doctor to get it checked. Also make an appointment with your doctor if you have other signs or symptoms that worry you.** **Bladder Cancer causes and treatment:** **Bladder cancer begins when cells in the bladder develop changes (mutations) in their DNA. A cell\'s DNA contains instructions that tell the cell what to do. The changes tell the cell to multiply rapidly and to go on living when healthy cells would die. The abnormal cells form a tumor that can invade and destroy normal body tissue. In time, the abnormal cells can break away and spread (metastasize) through the body.** **Types of bladder cancer** **Different types of cells in your bladder can become cancerous. The type of bladder cell where cancer begins determines the type of bladder cancer. Doctors use this information to determine which treatments may work best for you.** **Types of bladder cancer include:** - **Urothelial carcinoma. Urothelial carcinoma, previously called transitional cell carcinoma, occurs in the cells that line the inside of the bladder. Urothelial cells expand when your bladder is full and contract when your bladder is empty. These same cells line the inside of the ureters and the urethra, and cancers can form in those places as well. Urothelial carcinoma is the most common type of bladder cancer in the United States.** - **Squamous cell carcinoma. Squamous cell carcinoma is associated with chronic irritation of the bladder --- for instance, from an infection or from long-term use of a urinary catheter. Squamous cell bladder cancer is rare in the United States. It\'s more common in parts of the world where a certain parasitic infection (schistosomiasis) is a common cause of bladder infections.** - **Adenocarcinoma. Adenocarcinoma begins in cells that make up mucus-secreting glands in the bladder. Adenocarcinoma of the bladder is very rare.** **Some bladder cancers include more than one type of cell.** **Risk factors** **Factors that may increase bladder cancer risk include:** - **Smoking. Smoking cigarettes, cigars or pipes may increase the risk of bladder cancer by causing harmful chemicals to accumulate in the urine. When you smoke, your body processes the chemicals in the smoke and excretes some of them in your urine. These harmful chemicals may damage the lining of your bladder, which can increase your risk of cancer.** - **Increasing age. Bladder cancer risk increases as you age. Though it can occur at any age, most people diagnosed with bladder cancer are older than 55.** - **Being male. Men are more likely to develop bladder cancer than women are.** - **Exposure to certain chemicals. Your kidneys play a key role in filtering harmful chemicals from your bloodstream and moving them into your bladder. Because of this, it\'s thought that being around certain chemicals may increase the risk of bladder cancer. Chemicals linked to bladder cancer risk include arsenic and chemicals used in the manufacture of dyes, rubber, leather, textiles and paint products.** - **Previous cancer treatment. Treatment with the anti-cancer drug cyclophosphamide increases the risk of bladder cancer. People who received radiation treatments aimed at the pelvis for a previous cancer have a higher risk of developing bladder cancer.** - **Chronic bladder inflammation. Chronic or repeated urinary infections or inflammations (cystitis), such as might happen with long-term use of a urinary catheter, may increase the risk of a squamous cell bladder cancer. In some areas of the world, squamous cell carcinoma is linked to chronic bladder inflammation caused by the parasitic infection known as schistosomiasis.** - **Personal or family history of cancer. If you\'ve had bladder cancer, you\'re more likely to get it again. If one of your blood relatives --- a parent, sibling or child --- has a history of bladder cancer, you may have an increased risk of the disease, although it\'s rare for bladder cancer to run in families. A family history of Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC), can increase the risk of cancer in the urinary system, as well as in the colon, uterus, ovaries and other organ** **Chronic bacterial prostatitis :** **Chronic prostatitis is treated with fluoroquinolones or Bactrim x 6- 12 weeks** **Placenta abruptae presentation :** **Placental abruption is a serious condition that occurs when the placenta separates from the uterine wall before birth. Symptoms include: ** - **Vaginal bleeding, which can vary in amount and may not be visible ** - **Abdominal pain, which can begin suddenly ** - **Back pain ** - **Uterine tenderness or rigidity ** - **Uterine contractions that are frequent and don\'t relax ** - **Decreased fetal movement ** - **Blood in amniotic fluid ** - **Nausea and thirst ** - **Faint feeling ** **Placental abruption can occur at any time after 20 weeks of pregnancy, but it\'s most common in the last trimester. It can be a significant cause of maternal and neonatal morbidity and mortality. ** **A healthcare provider can diagnose placental abruption based on symptoms and an ultrasound. Other tests that can confirm placental abruption include:** - **Complete blood count** - **Fetal monitoring** - **Measuring fibrinogen levels** - **Pelvic exam** - **Platelet count** - **Vaginal ultrasoun** **Placenta previa presentation** **The main sign of placenta previa is bright red vaginal bleeding, usually without pain, after 20 weeks of pregnancy. Sometimes, spotting happens before an event with more blood loss. The bleeding may occur with prelabor contractions of the uterus that cause pain** **A patient presenting with vaginal bleeding in the second or third trimester should receive a transabdominal sonogram before a digital examination. If there is a concern for placenta previa, then a transvaginal sonogram should be performed to confirm the location of the placenta. Transvaginal sonogram has been shown to be superior to a transabdominal sonogram and is Low lying and marginal placentas are identified with sonography and are determined by measuring the distance of the edge of the placenta to the internal os.** **With the diagnosis of placenta previa, the patient is scheduled for elective delivery at 36 to 37 weeks via cesarean section.However, some patients with placenta previa present with complications and require urgent cesarean sections at an earlier gestational ag** **Symptoms of pre-eclampsia:** **Stage for amniocentesis:** **An amniocentesis is typically performed between 15 and 20 weeks of gestation during the second trimester of pregnancy; this is considered the standard stage for this procedure. ** **Key points about amniocentesis:** - **Reasoning for timing:** **This timeframe allows for sufficient amniotic fluid to be present for sampling while minimizing potential risks associated with performing the procedure too early in pregnancy. ** - **Procedure:** **A thin needle is inserted through the abdomen, guided by ultrasound, to extract a small amount of amniotic fluid for analysis in a lab. ** - **Purpose:** **This test can detect potential genetic abnormalities like Down syndrome, cystic fibrosis, or neural tube defects in the fetus. ** - **Risks:** **While considered a safe procedure, there is a small risk of miscarriage, which is why it\'s usually only recommended for women considered at higher risk for genetic issue** **Weight gain in pregnancy how much underweight normal overweight:** Underweight: BMI \< 18.5 28-40 lb Normal BMI: 18.5 - 24.9 25-35 lb Overweight: BMI 25- 29.9 15- 25 lb Obese: BMI ≥30 11- lb **Naegels rule:** -3 months + 7 days + 1 year **When to give Rhogam** -- is given to pregnant people with Rh D- blood at 28 weeks of gestation and protect for 12 weeks. Repeat dose at 72 hours post-partum. If a dose is needed before 28 weeks give a second dose within 12 weeks of the first dose. **Hegar sign:** Hegar\'s sign is a physical change that occurs in the cervix and uterus during pregnancy, indicating that a woman is likely pregnant:  The cervical isthmus, the part of the cervix closest to the uterus, softens and becomes more compressible. The lower part of the uterus feels soft compared to the cervix and the rest of the uterus.  Hegar\'s sign is usually noticeable between weeks four and 12 of pregnancy.  A medical professional can perform a bimanual examination to check for Hegar\'s sign. The examiner places two fingers in the anterior fornix and two fingers below the uterus, and feels for the softening of the lower uterus.  - **Significance** Hegar\'s sign was one of several methods used to detect pregnancy before reliable blood and urine tests were available. However, it\'s not a specific indicator of pregnancy, and its absence doesn\'t rule out pregnancy **Chadwick's sign**: Chadwick\'s sign is a common pregnancy symptom that appears as a bluish or purplish discoloration of the vulva, vaginal tissue, or cervix. It\'s caused by increased blood flow to the pelvis during early pregnancy and is usually not painful.  When it appears As early as 6 weeks after conception --------------------- ------------------------------------------------------------------------------- What it looks like Dark bluish or purplish discoloration of the vulva, vaginal tissue, or cervix What causes it Increased blood flow to the pelvis Pain Usually not painful What it lasts until Typically lasts until after delivery **Goodell's sign**: - **What it is**: The cervix softens due to increased blood flow and engorgement of blood vessels below the growing uterus. The cervix may also appear larger.  - **When it occurs**: Goodell\'s sign usually becomes noticeable between weeks 4 and 8 of pregnanc **Important gestational developmental stages feel fundal at the umbilicus :** **Fundal height is the distance between the top of your uterus and your pubic bone. Healthcare providers use it to measure if fetal growth is on track. Your fundal height is measured beginning at about 20 weeks in pregnancy. If the fetus measures smaller or larger than average, an ultrasound may be needed to get a more accurate size** **Your fundal height in centimeters should be close to the number of weeks you are in pregnancy, plus or minus 2 centimeters. However, this is only the case from about weeks 20 to 36. Before 20 weeks of pregnancy, your fundus is not high enough. After 36 weeks of pregnancy, your fundus starts to go down. This is because the fetus has dropped into your pelvis to prepare for labor. If this drop doesn\'t happen, this can indicate the fetus is [breech](https://my.clevelandclinic.org/health/diseases/21848-breech-baby).** **For example, if you are 32 weeks pregnant, a fundal height of 30 to 34 centimeters is an acceptable size** **Prenatal vitamins to prevent neural tube defect: 400 mcg** Folic Acid **Dx test to perform for pt who are infertile w/ varicocele:** **For a patient with infertility and a suspected varicocele, the primary diagnostic test to perform is a scrotal ultrasound, specifically with color Doppler imaging which allows for accurate visualization and assessment of the affected veins, including blood flow patterns, to confirm the presence of a varicocele and determine its severity; alongside this, a semen analysis is crucial to evaluate sperm quality and identify potential fertility issues related to the varicocele** **Varicocele: A varicocele (VAR-ih-koe-seel) is an enlargement of the veins within the loose bag of skin that holds the testicles (scrotum). These veins transport oxygen-depleted blood from the testicles. A varicocele occurs when blood pools in the veins rather than circulating efficiently out of the scrotum.** **Varicoceles usually form during puberty and develop over time. They may cause some discomfort or pain, but they often result in no symptoms or complications.** **A varicocele may cause poor development of a testicle, low sperm production or other problems that may lead to infertility. Surgery to treat varicocele may be recommended to address these complication** Diagnostics: A system of grading has been established to better define varicocele. Grade 1: varicocele is palpable only when the patient performs the Valsalva maneuver. Grade 2: Palpable when the patient is standing. Grade 3 varicocele may be assessed with the light palpation and visual inspection. Sperm count, and motility are significant decrease in patients with a varicocele approximately 65 to 75% of the time there is evidence of a progressive decline in fertility. Scrotal ultrasound venography (showing testicular Venus reflux from a varicocele) and thermographic (showing an increase in temperature at the varicocele) help to confirm the diagnosis. For a patient with a varicocele and suspected infertility, the primary diagnostic test is a semen analysis to assess sperm quality, including count, motility, and morphology, as this is the most direct way to evaluate if the varicocele is impacting fertility